|Year : 2016 | Volume
| Issue : 2 | Page : 77-81
Coronal leakage of provisional restorative materials used in endodontics with and without intracanal medication after exposure to human saliva
P Udayakumar1, Mamta Kaushik2, Neha Prashar2, Shikha Arya1
1 Department of Conservative Dentistry and Endodontics, SVS Institute of Dental Sciences, Apanapally, Mehabubnagar, Telangana, India
2 Department of Conservative Dentistry and Endodontics, Army College of Dental Sciences, Hyderabad, Telangana, India
|Date of Web Publication||18-Apr-2016|
SVS Institute of Dental Sciences, Apanapally, Mehabubnagar, Telangana
Source of Support: None, Conflict of Interest: None
Aim: To determine the coronal leakage of various provisional restorations with and without intracanal medication over time after being exposed to human saliva. Materials and Methods: This study investigated Coltosol F, Cavit, Ketac Molar, and IRM as provisional restorative material. Calcium hydroxide and chlorhexidine were used as an intracanal medicament. Ninety-eight single rooted teeth were randomly selected and then mounted in an apparatus that isolated the crown portion of the tooth. Provisional restorative materials were placed in the access cavity following manufacturer guidelines after placement of intracanal medicament. Human saliva and brain heart infusion broth in 3:1 ratio were applied to the samples, incubated at 37°C, and results were tabulated over the course of 4 weeks by the appearance of turbidity in the lower part of the apparatus. Statistical Analysis: The data were statistically analyzed using proportional Z-test. The level of significance was set at 0.05. Results: Coltosol F and Cavit could significantly prevent the bacterial leakage up to a period of 7 days with a P value of 0.01 and 0.005, respectively. Bacterial recontamination was relatively less in the samples treated with intracanal medicaments up to 14 days. After 14 days, however, all materials leaked in over half of the samples. Conclusion: No provisional restorative material can be considered superior in providing a reliable seal after 14 days. Inter-appointments schedule should not extend beyond 2 weeks and after endodontic therapy final restoration should be completed within 1 week.
Keywords: Bacteria, intracanal medicament, leakage, provisional restorations
|How to cite this article:|
Udayakumar P, Kaushik M, Prashar N, Arya S. Coronal leakage of provisional restorative materials used in endodontics with and without intracanal medication after exposure to human saliva. Saudi Endod J 2016;6:77-81
|How to cite this URL:|
Udayakumar P, Kaushik M, Prashar N, Arya S. Coronal leakage of provisional restorative materials used in endodontics with and without intracanal medication after exposure to human saliva. Saudi Endod J [serial online] 2016 [cited 2019 Dec 8];6:77-81. Available from: http://www.saudiendodj.com/text.asp?2016/6/2/77/180620
| Introduction|| |
The main reason for pulpal necrosis and periapical lesions is bacteria and their products.  Therefore, it is essential to eliminate bacteria from an infected root canal and also to prevent reinfection. The number of bacteria cannot be eliminated even after cleaning, shaping, and irrigating the root canal.  The bacterial count may increase in the canal between visits if an intracanal medicament is not used. , The access cavity should be sealed with a temporary provisional restorative materials such as Cavit, IRM, Coltosol F, and glass-ionomer to prevent recontamination of the canals. ,,,
Cavit is a premixed calcium sulfate-zinc oxide-based provisional restorative material. It is a hygroscopic material. Because of water sorption, Cavit has a high coefficient of linear expansion which is almost double to that of zinc oxide eugenol. Earlier, it was suggested that this property of linear expansion leads to a very good marginal seal.  However, later, in few studies, it was observed that Cavit showed body leakage even in conditions where it was allowed to set under water. ,
IRM is zinc oxide eugenol cement reinforced with polymethacrylate resin. Because of this reinforcement with resin, there is an improvement in compressive strength, abrasion resistance, and hardness of the cement.
Coltosol F is noneugenol, zinc oxide/zinc sulfate-based, self-setting temporary restorative material. It is single component cement which can be applied and removed easily. It gets hardened by absorption of water, with a hygroscopic expansion of 17-20% according to the manufacturer. Studies have shown that Coltosol F has good sealing ability for 2 weeks. , It has been shown that due to the high amount of hygroscopic expansion of Coltosol F, high pressure is created against the cavity walls causing cuspal deflection. 
The use of glass-ionomer cements as temporary restorative material has been suggested. They have an acceptable ability to seal because of their adhesion mechanism. None of the current provisional restorative materials used have proved to provide consistently good sealing properties. Additional or combinations of materials need to be investigated. 
The aim of the study was to determine the coronal leakage of various provisional restorations with and without intracanal medication over time after being exposed to human saliva.
| Materials and methods|| |
Ninety-eight caries-free, human single-rooted teeth with straight roots were selected for this study. Of the 98 teeth samples, a conventional access opening was prepared in 91 teeth. Canals were prepared with rotary ProTaper (Dentsply, Tulsa, OK, USA) up to size F2. In between files, the irrigation was carried out using 1 mL of 2.5% NaOCl and 17% EDTA for 3 min followed by 1 mL of 2.5% NaOCl to remove smear layer. A final rinse with 5 mL of sterile saline was done and then the canals were dried with paper points.
Each root was coated with cyanoacrylate to provide a final seal and then each tooth was inserted in a vial leaving the crown outside and the root inside. The apparatus was evaluated for leakage as described by Siqueira et al.  and then autoclaved at 121°C for 20 min. Samples of 84 teeth were randomly divided into four groups with 21 teeth in each group according to the coronal seal used.
In Group 1, Coltosol F (ColteneWhaldent, Allstetten, Switzerland) was used; in Group 2, Cavit (3M ESPE, Seefeld, Germany) was used; in Group 3, the provisional restoration was done with Ketac Molar (3M ESPE, Seefeld, Germany); and in Group 4, the provisional restoration was done with IRM (Dentsply; L. D. Caulk Co., Milford, DE, USA). These groups were further divided into three subgroups according to the intracanal medicament used with seven teeth in each subgroup as follows:
In seven samples, neither intracanal medication nor coronal seal was placed in the prepared canals, which served as positive control whereas the remaining seven intact teeth served as negative control. CaOH powder (Biodinamica, Ibipora, PR, Brazil) in distilled water and commercially available 2% CHX (Amrit Chem. Mohali) was used.
- Subgroup A: No medication
- Subgroup B: Calcium hydroxide (CaOH)
- Subgroup C: Chlorhexidine (CHX).
The depth of the cavity was approximately 4 mm from the canal orifice to the cavosurface margin.  The medicaments were placed into the root canals. Sterile cotton pellet was placed in the pulp chamber. The teeth had their coronal access filled with respective provisional restorative material. The restorative materials were left for 1 h to set before microbial leakage test.
The bottom test tube was filled with brain heart infusion (BHI) agar (BD) using sterile pipettes (Fisher Scientific, India). Cyanoacrylate was applied between the flask and the stopper to avoid saliva penetration into the BHI broth [Figure 1].
|Figure 1: Apparatus with isolated crown portion of the tooth and root immersed in a combination of human saliva and brain heart infusion broth|
Click here to view
Human saliva was collected from volunteers who did not brush or floss for at least 12 h before collection. Human saliva and BHI broth were maintained in 1:3 proportions and it was applied to crown section twice daily. The apparatus was incubated at 37°C and checked daily for turbidity according to Verissimo et al. 
The presence or absence of turbidity was determined by a single observer at 7, 14, 21, and 28 days. Data were analyzed statistically using proportional Z-test. The level of significance was set at 0.05.
| Results|| |
The percentage leakage of all the test groups after 7, 14, and 18 days is summarized in [Table 1].
Throughout the study period, negative samples showed no turbidity while turbidity was observed in positive controls.
After 7 days, Ketac Molar and IRM showed the maximum leakage with a P = 0.05. No statistical significant difference was found between Ketac Molar and IRM and positive control. However, they showed statistically significant difference with Coltosol CHX with a P = 0.0001.
After 14 days, maximum leakage was observed in samples with Ketac Molar as temporary restoration without intracanal medication and minimum leakage was observed in teeth restored with Coltosol and CaOH as medicament and also in group restored with Ketac Molar and CaOH with a P = 0.005.
After 18 days, 100% leakage was observed in groups containing IRM without medication and with CHX as medicament and group restored with Ketac Molar without medicament. Minimum leakage was observed in Coltosol and CaOH with a P = 0.005.
After 21 days, almost all of the groups showed leakage with statistically no significant difference with positive control.
| Discussion|| |
To test intracanal medication, a number of leakage studies using bacterial cultures or saliva have been done. ,, When compared to dye leakage test, the method used in this study has a more biological and clinical relevance.  As the dye has a low molecular weight and can penetrate into sites where bacterial cells cannot, the results observed in this methodology have been questioned. As human saliva has different bacterial species and bacterial products, it has more advantages when compared with bacterial cultures. Natural saliva has enzymes and proteins mimicking real clinical situation, which is not provided by culture media and dye leakage test. 
Determining bacterial leakage associated with provisional restorative materials used during endodontic treatment is important because one of the ideal properties of these materials is to prevent recontamination of the root canal system with oral bacteria between appointments. Therefore, any amount of leakage contributes to overall contamination and will ultimately lead to failure of completed nonsurgical root canal therapy. ,,,
Coltosol F and Cavit have shown good sealing properties. In the current study, no provisional restorative material was completely resistant to bacterial leakage, with 60-70% of the specimens in all experimental groups demonstrating leakage after 14 days, except with intracanal medicaments.
Previous studies have shown that Ketac Molar performs well under loading; however, its sealing ability has proved to be inferior to Cavit in several studies. ,, It has been shown that Cavit has superior sealing qualities, even in complex access cavities.  In the present study, Cavit has shown lesser percentage of leakage when compared to Ketac Molar after 7, 14, and 21 days. However, Cavit's ability to seal is limited by its low resistance to mechanical loading.  IRM, with and without mechanical loading, has shown to perform poorly in leakage studies. ,,,, The present study is in agreement with these studies as IRM showed a high percentage of leakage when compared to Cavit and Coltosol F.
Good results obtained by Coltosol F and Cavit may be contributed to the fact that these restorative materials undergo hygroscopic expansion over time. However, hygroscopic expansion in Coltosol F can lead to cuspal deflection, infraction, and fracture of weak structures in endodontically treated teeth. 
To prevent the entry of saliva and microorganisms into the root canal and to prevent leaching of the intracanal medicament into the oral cavity, it is important to seal the access cavity with a temporary restorative material in between appointments. Intracanal medicament helps decreasing the amount of microleakage and bacterial contamination inside the canal. , As the setting time ranges from 5 min for IRM to 30 min for Coltosol F according to the manufacturer, the samples were left for a period of 1 h to set for the purpose of standardization.
In the present study, CaOH mixed with distilled water was used as it does not decrease the microhardness of root dentin when compared to other vehicles which are used to mix CaOH powder. 
The percentage of leakage in all the samples, except for Cavit + CHX and IRM + CHX, was comparatively less in the samples with intracanal medicament than the samples without any medication. CaOH had shown better antibacterial property than CHX to prevent leakage overtime. Coltosol F with CaOH, Coltosol F with CHX, and Cavit with CaOH had shown least bacterial leakage up to 18 days. The current study is in agreement with the study conducted by Gomes et al.  where the time for microleakage to occur was less for IRM alone when compared to IRM + CaOH.
It is very important to advise patients not to delay the final restoration of the endodontically treated teeth for a successful outcome. Selection of good provisional restorative material helps prevent leakage between visits.
Limitation of the study
This present study examined the minimum expected insult of bacterial leakage against provisional restorative materials without any mechanical loading. The apparatus used in this study is a limited static model that does not simulate some conditions found in the oral cavity, such as temperature changes, diet, and salivary flow.
| Conclusion|| |
All of the coronal restorations tested failed to prevent leakage beyond 7 days where Ketac Molar and IRM had the poorest resistance to bacterial leakage. In addition, bacterial recontamination can be prolonged by placing intracanal medication up to 14 days. No provisional restoration with intracanal medication could prevent leakage beyond 21 days. Thus, inter-appointments schedule should not extend beyond 2 weeks and after endodontic therapy final restoration should be completed within 1 week.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Pinheiro ET, Gomes BP, Ferraz CC, Sousa EL, Teixeira FB, Souza-Filho FJ. Microorganisms from canals of root-filled teeth with periapical lesions. Int Endod J 2003;36:1-11.
Peters LB, Wesselink PR. Periapical healing of endodontically treated teeth in one and two visits obturated in the presence or absence of detectable microorganisms. Int Endod J 2002;35:660-7.
Gurgel-Filho ED, Vivacqua-Gomes N, Gomes BP, Ferraz CC, Zaia AA, Souza-Filho FJ. In vitro
evaluation of the effectiveness of the chemomechanical preparation against Enterococcus faecalis
after single- or multiple-visit root canal treatment. Braz Oral Res 2007;21:308-13.
Almyroudi A, Mackenzie D, McHugh S, Saunders WP. The effectiveness of various disinfectants used as endodontic intracanal medications: An in vitro
study. J Endod 2002;28:163-7.
Ray HA, Trope M. Periapical status of endodontically treated teeth in relation to the technical quality of the root filling and the coronal restoration. Int Endod J 1995;28:12-8.
Kirkevang LL, Ørstavik D, Hörsted-Bindslev P, Wenzel A. Periapical status and quality of root fillings and coronal restorations in a Danish population. Int Endod J 2000;33:509-15.
Begotka BA, Hartwell GR. The importance of the coronal seal following root canal treatment. Va Dent J 1996;73:8-10.
Saunders WP, Saunders EM. Coronal leakage as a cause of failure in root-canal therapy: A review. Endod Dent Traumatol 1994;10:105-8.
Webber RT, del Rio CE, Brady JM, Segall RO. Sealing quality of a temporary filling material. Oral Surg Oral Med Oral Pathol 1978;46:123-30.
Tamse A, Ben-Amar A, Gover A. Sealing properties of temporary filling materials used in endodontics. J Endod 1982;8:322-5.
Kazemi RB, Safavi KE, Spångberg LS. Assessment of marginal stability and permeability of an interim restorative endodontic material. Oral Surg Oral Med Oral Pathol 1994;78:788-96.
Madarati A, Rekab MS, Watts DC, Qualtrough A. Time-dependence of coronal seal of temporary materials used in endodontics. Aust Endod J 2008;34:89-93.
Naseri M, Ahangari Z, Shahbazi Moghadam M, Mohammadian M. Coronal sealing ability of three temporary filling materials. Iran Endod J 2012;7:20-4.
Laustsen MH, Munksgaard EC, Reit C, Bjørndal L. A temporary filling material may cause cusp deflection, infractions and fractures in endodontically treated teeth. Int Endod J 2005;38:653-7.
Hartwell GR, Loucks CA, Reavley BA. Bacterial leakage of provisional restorative materials used in endodontics. Quintessence Int 2010;41:335-9.
Siqueira JF Jr, Rôças IN, Lopes HP, de Uzeda M. Coronal leakage of two root canal sealers containing calcium hydroxide after exposure to human saliva. J Endod 1999;25:14-6.
Gomes BP, Sato E, Ferraz CC, Teixeira FB, Zaia AA, Souza-Filho FJ. Evaluation of time required for recontamination of coronally sealed canals medicated with calcium hydroxide and chlorhexidine. Int Endod J 2003;36:604-9.
Verissimo RD, Gurgel-Filho ED, De-Deus G, Coutinho-Filho T, de Souza-Filho FJ. Coronal leakage of four intracanal medications after exposure to human saliva in the presence of a temporary filling material. Indian J Dent Res 2010;21:35-9.
Zaia AA, Nakagawa R, De Quadros I, Gomes BP, Ferraz CC, Teixeira FB, et al.
An in vitro
evaluation of four materials as barriers to coronal microleakage in root-filled teeth. Int Endod J 2002;35:729-34.
Siqueira JF Jr, Lopes HP, de Uzeda M. Recontamination of coronally unsealed root canals medicated with camphorated paramonochlorophenol or calcium hydroxide pastes after saliva challenge. J Endod 1998;24:11-4.
Barthel CR, Strobach A, Briedigkeit H, Göbel UB, Roulet JF. Leakage in roots coronally sealed with different temporary fillings. J Endod 1999;25:731-4.
Balto H. An assessment of microbial coronal leakage of temporary filling materials in endodontically treated teeth. J Endod 2002;28:762-4.
Hagemeier MK, Cooley RL, Hicks JL. Microleakage of five temporary endodontic restorative materials. J Esthet Dent 1990;2:166-9.
Jensen AL, Abbott PV. Experimental model: Dye penetration of extensive interim restorations used during endodontic treatment while under load in a multiple axis chewing simulator. J Endod 2007;33:1243-6.
Lim KC. Microleakage of intermediate restorative materials. J Endod 1990;16:116-8.
Lai YY, Pai L, Chen CP. Marginal leakage of different temporary restorations in standardized complex endodontic access preparations. J Endod 2007;33:875-8.
Liberman R, Ben-Amar A, Frayberg E, Abramovitz I, Metzger Z. Effect of repeated vertical loads on microleakage of IRM and calcium sulfate-based temporary fillings. J Endod 2001;27:724-9.
Bobotis HG, Anderson RW, Pashley DH, Pantera EA Jr. A microleakage study of temporary restorative materials used in endodontics. J Endod 1989;15:569-72.
Pacios MG, Lagarrigue G, Nieva N, María EL. Effect of calcium hydroxide pastes and vehicles on root canal dentin microhardness. Saudi Endod J 2014;4:53-7.